WRAPAROUND MILWAUKEE Policy & Procedure

Tamaño: px
Comenzar la demostración a partir de la página:

Download "WRAPAROUND MILWAUKEE Policy & Procedure"

Transcripción

1 WRAPAROUND MILWAUKEE Policy & Procedure Issued: 9/1/98 Reviewed: 10/18/11 By: PE Last Revision: 11/11/11 Section: ADMINISTRATION Policy No: 011 Pages: 1 of 2 (3 Attachments) Wraparound Wraparound-REACH FISS Project O-Yeah Effective : 1/1/12 Subject: CONSENT / ACKNOWLEDGEMENT AND AUTHORIZATION FORMS I. POLICY It is the policy of Wraparound Milwaukee / REACH to have the youth and a parent/legal guardian sign the identified Consent/Acknowledgment and Authorization For Release of Information forms during the initial face-to-face contact that the Care Coordinator has with the family. The initial face-to-face contact must occur within the first seven (7) calendar days of enrollment (first 5 working days). The purpose of the Consent/Acknowledgement Form is to receive permission from the youth and parent or legal guardian for the following: CONSENT/ACKNOWLEDGEMENT FORM (see Attachment 1) - to allow Wraparound Milwaukee /REACH personnel and/or providers/identified persons to transport youth, to acknowledge receipt of the Client Rights and Complaint/Grievance Procedure handout, and to acknowledge receipt of the Wraparound HIPAA Privacy Statement. The purpose of the Authorization for Release of Information Form is to receive permission from the youth and parent/legal guardian for the following: AUTHORIZATION FOR RELEASE OF INFORMATION forms (see Attachment 2/2A for Spanish) - to allow Wraparound Milwaukee / REACH personnel to give or receive information with or from specific identified agencies/persons. Note: Also see Mobile Urgent Treatment Team (MUTT) Consent for Treatment Policy (#027). II. PROCEDURE The Care Coordinator will receive the necessary Consent/Acknowledgement and Authorization for Release of Information Forms in the enrollment packet when they are assigned to work with a family. The Care Coordinator is responsible for getting the necessary signatures during the first visit with the youth/family, which must occur during the first week of enrollment (first 5 working days). Wraparound youth under the age of 14 (at admission) are not required to sign the Wraparound/REACH or MUTT Consent Forms. Youth age 14 and older should sign, but if a youth s signature cannot be obtained for whatever reason, the parent s/legal guardian s signature alone will suffice. If a youth is not 14 years of age when he/she enters the program, but turns 14 during the course of the first year in Wraparound, he/she should sign the Consents at the one year time frame when all Consents need to be renewed/resigned. Note: Exchange of information and formal Wraparound / REACH services cannot legally occur without the forms being signed. The Forms must then become a permanent part of the youth s file. Copies must be shared with identified parties as information needs to be shared/given/received. All Consent/Acknowledgement and Authorization forms expire 12 months from the date they were signed and then every subsequent 12 months. Therefore, Consents need to be signed at enrollment, 12 months, 24 months, 36 months, etc. Consents and Authorizations can be canceled/revoked at any time. This must be done in writing.

2 Consents Policy Page 2 of 2 Requests to revoke and refusals to sign Consent or Authorization forms are to be immediately forwarded for processing to the Wraparound Quality Assurance Director, as identified on the form. A. Consent/Acknowledgement Form. 1. The Care Coordinator is responsible for explaining each item on the Consent/Acknowledgement form. 2. The parent/guardian, and the youth if they desire, should initial each item. This signifies consent to that item or acknowledgment of receipt of the Client Rights and Complaint/Grievance Procedure handout, and Wraparound HIPAA Privacy Statement. 3. The Care Coordinator is to offer an overview of the Client Rights and Complaint/Grievance Procedure information contained in the Clients Rights and Compliant/Grievance Procedure handout and answer any questions that the youth or family might have. 4. The Care Coordinator is to offer an overview of the Wraparound HIPAA Privacy Statement and answer any questions that the youth or family might have. 5. The signed Consent/Acknowledgement Form is to be placed in the client record in the Intake/Consents Section. 6. Upon Request, a copy of the form is to be given to the legal guardian/youth (per HFS 9403(3)). B. Authorization for Release of Information Form. 1. The Care Coordinator is responsible for explaining that signing the Authorization for Release of Information Form allows Wraparound Milwaukee to exchange information with the agencies/persons listed on the form. The family may withdraw the authorization to release information by submitting a written request to the Wraparound Quality Assurance Director, as identified on the form. 2. A copy of the Authorization for Release of Information Form must be given to the family. This form will be completed and signed at enrollment by the Wraparound Milwaukee Initial Assessment Worker. 3. Copies must also be shared with parties identified as receiving/exchanging information. 4. Additional Authorization for Release of Information Forms must be completed for new service providers (see Attachment 4). For example, if a new service Provider is introduced and is not listed on the original Authorization for Release of Information Form, another form must be completed and signed/dated by the parent/legal guardian before the Care Coordinator can release/exchange information or make referrals to that Provider. 5. After the form(s) is(are) signed, the Authorization for Release of Information Form becomes a permanent part of the client record and should be placed in the Intake/Consents Section. Upon completion of the Release of Information form, the Care Coordination Agency clerical support staff will also indicate in Synthesis (Wraparound Milwaukee s IT system) those individuals/ agencies/community resources that are listed on the form for which the family has given permission for Wraparound Milwaukee to release/exchange information with. Reviewed & Approved by: DDJ 11/11/11 - ConsentsPolicy Bruce Kamradt, Director

3 Consents Policy Attachment 1 WRAPAROUND MILWAUKEE CONSENT/ACKNOWLEDGEMENT FORM The following items are essential to the care of you and/or your family while participating in Wraparound Milwaukee and its programs. Please review each area and indicate which areas you approve by initialing the appropriate line after each heading. Initial to Approve 1. ACKNOWLEDGEMENT OF RECEIPT OF CLIENTS RIGHTS & COMPLAINT/GRIEVANCE PROCEDURE I have read and understand my legal client rights as a participant of a Wraparound Milwaukee programs and recipient of services provided through the Provider Network. By signing below I acknowledge that I have received a copy of the Client Rights and Grievance Procedure handout. 2. ACKNOWLEDGEMENT OF RECEIPT OF PRIVACY STATEMENT I have received, read and understand the Privacy Statement, and understand the program s commitment to protecting any identifiable client information as mandated by law. 3. CONSENT FOR TRANSPORTATION I hereby give my consent for me and/or my children to be transported by Wraparound Milwaukee program staff and its agents as needed. Unless otherwise specified below, this consent will expire 12 months from the date it was signed. This consent or any part of this consent may be canceled at any time with written notification as outlined on the back of this form. Enrollee Name (please print) of Birth (, event or condition upon which consent will expire) Parent or Legal Guardian s Signature (required if enrollee under age 18) Enrollee s Signature Witness Signature YOUR RIGHTS WITH RESPECT TO THIS CONSENT: Right to Refuse to Sign This Consent/Acknowledgement Form - I understand that I am under no obligation to sign this form and that Wraparound Milwaukee may not condition treatment, payment, or enrollment on my decision to sign this authorization. Right to Withdraw This Consent - I understand that I have the right to withdraw consent for any of the items identified on the previous page at any time by providing a written statement of withdrawal to Pamela Erdman, Wraparound Quality Assurance. (The statement must identify what Consent that is being withdrawn, be dated and signed). I am aware that my withdrawal will not be effective until received by Wraparound Milwaukee. Submit your written request for withdrawal to: Ms. Pamela Erdman, Quality Assurance Director Wraparound Milwaukee 9201 Watertown Plank Road Milwaukee, WI (414) Consent/Acknowledge Form 10-07, 10-08, 08-10

4 Consents Policy Attachment 2 WRAPAROUND MILWAUKEE / REACH AUTHORIZATION TO RELEASE/EXCHANGE INFORMATION PURPOSE OF INFORMATION RELEASE/EXCHANGE: Release / exchange of mental health (Enrollment notification and information, Plan of Care including diagnosis/prognosis, and Progress Reports) AODA (Alcohol and Other Drug Addiction), physical health and school progress information that will be used to plan and provide for the care, treatment and services for: (Youth s Name) ( of Birth) I authorize Wraparound Milwaukee, its contracted Care Coordination Agencies, and the Mobile Urgent Treatment Team to release and exchange information with staff at the agencies identified below. Information may be shared verbally or in writing. Place your initials in the box next to the agency name to authorize information release/exchange. AGENCY NAME Insurance Carrier - Medicaid / Title 19 Insurance Carrier Other (Insurance Company Name) Bureau of Milwaukee Child Welfare Milwaukee County Children s Court Chris Shafer, Laverne Lunde, Wraparound Education Advocates Shirley Fishman ADDITIONAL INFO. TO BE RELEASED/EXCHANGED Families United of Milwaukee, Inc. (Family Advocacy Agency) Milwaukee Public Schools (School Name) Other Schools (School Name) Primary Care Physician (Physician (Clinic Name / Other-Name Address: Youth in Wraparound and REACH are also encouraged to participate in our Wraparound Youth Council and Clubhouse activities. By initialing here you authorize Youth Council representatives to contact your child directly regarding activities and events. CONSENT FOR INFORMATION TO BE USED IN RESEARCH I give my consent for non-identifying data obtained during my enrollment to be used for research to evaluate the effectiveness of the program. No information that is presented will contain any identifying personal information. EXPIRATION OF AUTHORIZATION / WITHDRAWAL OF AUTHORIZATION If not specified below, I understand that this Authorization to Release/Exchange Information EXPIRES 12 MONTHS from the date it is signed. I understand that I may cancel this authorization at any time (see back of sheet for instructions). This cancellation does not include any information that has been shared between the time I gave my consent to share information and the time that the consent was canceled. This authorization expires on the day of, 20. REDISCLOSURE NOTICE: I understand that information used or disclosed based on this authorization may be subject to redisclosure and no longer protected by Federal privacy standards. Parent or Legal Guardian Signature Youth Signature (age 14 and older should sign) Witness Signature

5 PARTICIPANT RIGHTS RELATED TO AUTHORIZATION TO RELEASE/EXCHANGE INFORMATION YOUR RIGHTS WITH RESPECT TO THIS AUTHORIZATION: Right to Receive Copy of This Authorization - I understand that if I sign this authorization, I will be provided with a copy of this authorization. Right to Refuse to Sign This Authorization - I understand that I am under no obligation to sign this form and that Wraparound Milwaukee may not condition treatment, payment, or enrollment on my decision to sign this authorization. Failure to Sign - I understand that failure to sign this authorization may severely limit the treatment / service options available for my child or family. If my child is enrolled in Wraparound Milwaukee as part of a court order, I understand that failure to sign this form may result in a request to the courts to modify the court order that allows for enrollment in the Wraparound Milwaukee program. Right to Withdraw This Authorization - I understand that I have the right to withdraw this authorization at any time by providing a written statement of withdrawal to Pamela Erdman, Wraparound Milwaukee Quality Assurance. (The statement must be dated and signed). I am aware that my withdrawal will not be effective until received by Wraparound Milwaukee and will not be effective regarding the uses and/or disclosures of my health information that Wraparound Milwaukee has made prior to receipt of my withdrawal statement Right to Inspect or Copy the Health Information to Be Used or Disclosed - I understand that I have the right to inspect or copy (may be provided at a reasonable fee) the health information I have authorized to be released/exchanged by this authorization form. I may arrange to inspect my health information or obtain copies of my health information by contacting Pamela Erdman in the Wraparound Milwaukee Quality Assurance Department. HIV Test Results - I understand my child s HIV test results may be released without authorization to persons/organizations that have access under State law and a list of those persons/organizations is available upon request. Submit your written requests for withdrawal to: Ms. Pamela Erdman, Wraparound Milwaukee Quality Assurance Director Wraparound Milwaukee Administrative Offices 9201 Watertown Plank Road Milwaukee, WI Phone: (414) H/catc/wrapcmn/Forms/Authorization for Release-Exchange Form March2011

6 Consent Forms Policy Attachment 2a WRAPAROUND MILWAUKEE AUTORIZACIÓN PARA HACER LA INFORMACIÓN PÚBLICA PROPÓSITO DE DIVULGACIÓN: Hacer pública información de Salud Mental y AODA (Alcohol y Otras Adicciones a Drogas) y de de salud física la cual será utilizada para planificar y proveer para el cuidado, tratamiento, y servicios para: (Nombre del Joven) (Fecha de Nacimiento) Yo autorizo a Wraparound Milwaukee, sus agencias de contrato de coordinación de cuidado, y/o el Equipo Urgente Móvil del Tratamiento Para sacar/intercambiar información relacionado con la salud incluyendo diagnosis, pronostico, de tratamiento y planificación relacionado con el nombre de la parte superior del joven en Wraparound Milwaukee para el personal apropiado y las siguientes agencias que autoricen inscripción o proveen servicios de emergencias para familias alistadas en el programa de Wraparound Milwaukee. Corte de los niños del condado de Milwaukee Medicaid/Titulo 19 Oficina del bienestar del niño de Milwaukeee Además, yo autorizo soltar de información relacionado al nombre del joven de la parte superior para las siguientes agencias identificadas a la parte de abajo para el propósitos de planificar para y de la entrega del cuidado medico mental en curso, del cuidado medico físico y de los servicios de la educación. PONGA UNA X EN LA CAJA AL LADO DEL NOMBRE DE LA AGENCIA PARA AUTORIZAR INFORMACIÓN SOLTADA NOMBRE DE LA AGENCIA INFORMACION QUE PUEDE SER LANZADA Familias Unidas de Milwaukee, Inc. (abogado de la familia) Chris Shafer, Kay Abogado de la Educación de Wraparound Frederick, Shirley Fishman Información Democrática solamente Plan de cuidado, Diagnostico, del progreso y de los informes de la escuela Escuelas Publicas de Milwaukee (Entre Nombre de la Escuela) Plan de cuidado, Diagnostico, del progreso y de los informes de la escuela Otra Escuela (Entre Nombre de la Escuela) Plan de cuidado, Diagnostico, del progreso y de los informes de la escuela Medico Primario del cuidado (Entre el nombre del medico o de la clínica Proveedor de Servicios Dental (Entre el Nombre del Dentista o de la clínica) Siquiatra (Entre el Nombre del medico o de la clínica) Otro (Entre el Nombre de la agencia o del proveedor) Plan de cuidado, Diagnostico, y informes de progreso Plan de cuidado, Diagnostico, y informes de progreso Plan de cuidado, Diagnostico, y informes de progreso Plan de cuidado, Diagnostico, y informes de progreso CONSENTIMIENTO PARA QUE LA INFORMACION SE USADA EN LA INVESTIGACION Yo doy mi consentimiento para los datos de la evaluación no-que identifican obtenidos durante mi inscripción en Wraparound que se utilizara para la investigación para evaluar la eficacia del programa. Yo entiendo que la investigación puede ser presentada en conferencias, universidades y en publicaciones. Yo entiendo que la información recogida para la investigación es parte de los procedimientos generalmente de la evaluación de Wraparound. Yo entiendo que el confidencial de mi familia será protegido. Ninguna información que es presentada al público contendrá cualquier información que identifica tal como nombre, dirección o número de teléfono. EXPIRACION DE AUTORIZACION / RETIRO DE LA AUTORIZACION Si no especificado abajo, yo entiendo que esta Autorización para el lanzamiento de información EXPIRA en 12 meses a partir de la fecha que fue firmado. Yo entiendo que puedo cancelar esta autorización en cualquier momento (véase detrás de la hoja para las instrucciones). Esto no incluye ninguna información que se haya compartido entre el tiempo que di mi consentimiento a la información de la parte y al tiempo que el consentimiento fue cancelado. Esta autorización expira en día del, 20. AVISO DE REVELACION: Yo entiendo que la información que se utilizo o se revelo basado en la autorización puede estar conforme a re-acceso y protegido no más por estándares federales del aislamiento. Firma del Padre o Guardián Legal Día Firma del Joven (edad de 14 años o mayor debe firmar) Día R4 AuthorizationforReleaseFormSpanish.doc Page 1 of 2

7 Firma del Testigo Día LOS DERECHOS DEL CLIENTE RELACIONADOS CON LA AUTORIZACION DE LANZAMIENTO DE INFORMACION SUS DERECHOS CON RESPECTO A ESTA AUTORIZACION: El derecho de recibir una copia de esta Autorización Yo entiendo que si firmo esta autorización, yo seré proporcionado una copia de esta autorización. Derecho a Rechazar a Firmar esta Autorización Yo entiendo que no estoy bajo ninguna obligación de firmar esta forma y que el Wraparound Milwaukee no puede condicionar el tratamiento, el pago, o la inscripción en mi decisión de firmar esta autorización. Falta de Firma Yo entiendo que la falta de firmar esta autorización puede limitar seriamente las opciones del tratamiento/de servicios disponibles para mi niño o familia y/o puede dar lugar a una petición a las cortes de modificar el orden judicial que permite la inscripción en el programa de Milwaukee del Wraparound. Derecho a Retirar esta Autorización Yo entiendo que tengo el derecho de retirar esta autorización en cualquier momento proporcionando una declaración escrita del retiro a Pamela Erdman, garantía de calidad de Milwaukee del Wraparound y no será eficaz con respeto a las aplicaciones y/o los accesos de mi información de la salud que Wraparound Milwaukee a hecho antes de recibo de mi declaración de retiro. Derecho a Examinar o Copiar la Información de la Salud que se Utilizara o Divulgara Yo entiendo que tengo el derecho de examinar o de copiar (puede ser proporcionado en una razonable cuota) la información de la salud que he autorizado para ser utilizado o para ser divulgado por esta forma de la autorización. Puedo arreglar para examinar mi información de la salud e obtener copias de mi información de la salud entrando en contacto con Pamela Erdman en el departamento de la garantía de calidad de Milwaukee Wraparound. Resultado de la prueba de HIV Yo entiendo que los resultados de la prueba de HIV de mi niño se pueden lanzar sin la autorización a las personas/a las organizaciones que tienen acceso bajo la ley del estado y una lista de esas personas/organizaciones esta disponible a petición. Someta sus peticiones escritas para el retiro a: Ms. Pamela Erdman, Directora de la garantía de calidad de Wraparound Milwaukee Oficinas Administrativas de Wraparound Milwaukee 9201 Watertown Plank Road Milwaukee, WI Teléfono: (414) R4 AuthorizationforReleaseFormSpanish.doc Page 2 of 2

8 Consent Forms Policy Attachment 3 WRAPAROUND MILWAUKEE / REACH AUTHORIZATION TO RELEASE/EXCHANGE INFORMATION PURPOSE OF INFORMATION RELEASE/EXCHANGE: Release / exchange of mental health (Enrollment notification and information, Plan of Care including diagnosis/prognosis, and Progress Reports) AODA (Alcohol and Other Drug Addiction), physical health, school progress information and *Other documents that will be used to plan and provide for the care, treatment and services for: (Youth s Name) ( of Birth) I authorize Wraparound Milwaukee, its contracted Care Coordination Agencies, and the Mobile Urgent Treatment Team to release and exchange information with staff at the agencies identified below. Information may be shared verbally or in writing. 1. Agency/Individual (please print): Address (please print): *Identify Other Document/s: 2. Agency/Individual (please print): Address (please print): *Identify Other Document/s: 3. Agency/Individual (please print): Address (please print): *Identify Other Document/s: 4. Agency/Individual (please print): Address (please print): *Identify Other Document/s: AGENCY NAME / INDIVIDUAL NAME EXPIRATION OF AUTHORIZATION / WITHDRAWAL OF AUTHORIZATION If not specified below, I understand that this Authorization to Release/Exchange Information EXPIRES 12 MONTHS from the date it is signed. I understand that I may cancel this authorization at any time (see back of sheet for instructions). This cancellation does not include any information that has been shared between the time I gave my consent to share information and the time that the consent was canceled. This authorization expires on the day of, 20. REDISCLOSURE NOTICE: I understand that information used or disclosed based on this authorization may be subject to redisclosure and no longer protected by Federal privacy standards. Parent or Legal Guardian Signature Youth Signature (age 14 and older should sign) Witness Signature H/catc/wrapcmn/Forms/Authorization for Release Later Use March 2011 Page 1 of

9 PARTICIPANT RIGHTS RELATED TO AUTHORIZATION TO RELEASE/EXCHANGE INFORMATION YOUR RIGHTS WITH RESPECT TO THIS AUTHORIZATION: Right to Receive Copy of This Authorization - I understand that if I sign this authorization, I will be provided with a copy of this authorization. Right to Refuse to Sign This Authorization - I understand that I am under no obligation to sign this form and that Wraparound Milwaukee may not condition treatment, payment, or enrollment on my decision to sign this authorization. Failure to Sign - I understand that failure to sign this authorization may severely limit the treatment / service options available for my child or family. If my child is enrolled in Wraparound Milwaukee as part of a court order, I understand that failure to sign this form may result in a request to the courts to modify the court order that allows for enrollment in the Wraparound Milwaukee program. Right to Withdraw This Authorization - I understand that I have the right to withdraw this authorization at any time by providing a written statement of withdrawal to Pamela Erdman, Wraparound Milwaukee Quality Assurance. (The statement must be dated and signed). I am aware that my withdrawal will not be effective until received by Wraparound Milwaukee and will not be effective regarding the uses and/or disclosures of my health information that Wraparound Milwaukee has made prior to receipt of my withdrawal statement Right to Inspect or Copy the Health Information to Be Used or Disclosed - I understand that I have the right to inspect or copy (may be provided at a reasonable fee) the health information I have authorized to be released/exchanged by this authorization form. I may arrange to inspect my health information or obtain copies of my health information by contacting Pamela Erdman in the Wraparound Milwaukee Quality Assurance Department. HIV Test Results - I understand my child s HIV test results may be released without authorization to persons/organizations that have access under State law and a list of those persons/organizations is available upon request. Submit your written requests for withdrawal to: Ms. Pamela Erdman, Wraparound Milwaukee Quality Assurance Director Wraparound Milwaukee Administrative Offices 9201 Watertown Plank Road Milwaukee, WI Phone: (414) H/catc/wrapcmn/Forms/Authorization for Release Later Use March 2011 Page 2 of

AUTHORIZATION FOR USE OR DISCLOSURE OF HEALTH INFORMATION

AUTHORIZATION FOR USE OR DISCLOSURE OF HEALTH INFORMATION FORM 16-1 AUTHORIZATION FOR USE OR DISCLOSURE OF HEALTH INFORMATION Completion of this document authorizes the disclosure and use of health information about you. Failure to provide all information requested

Más detalles

FORMULARIO DE AUTORIZACIÓN MIM #710-S AUTHORIZATION FORM MIM #710-S

FORMULARIO DE AUTORIZACIÓN MIM #710-S AUTHORIZATION FORM MIM #710-S FORMULARIO DE AUTORIZACIÓN MIM #710-S AUTHORIZATION FORM MIM #710-S 500 Eastowne Drive Chapel Hill, NC 27514 Para radiografías favor de enviar a: Radiology Films please send: ATTN: IMAGING SUPPORT (919)

Más detalles

The Home Language Survey (HLS) and Identification of Students

The Home Language Survey (HLS) and Identification of Students The Home Language Survey (HLS) and Identification of Students The Home Language Survey (HLS) is the document used to determine a student that speaks a language other than English. Identification of a language

Más detalles

AGENCY POLICY: REVIEW OF NOTICE OF PRIVACY PRACTICES

AGENCY POLICY: REVIEW OF NOTICE OF PRIVACY PRACTICES AGENCY POLICY: REVIEW OF NOTICE OF PRIVACY PRACTICES SCOPE OF POLICY This policy applies to all agency staff members. Agency staff members include all employees, trainees, volunteers, consultants, students,

Más detalles

www.deltadentalins.com/language_survey.html

www.deltadentalins.com/language_survey.html Survey Code: Survey 1 February 6, 2008 Dear Delta Dental Enrollee: Recent changes in California law will require that all health care plans provide language assistance to their plan enrollees beginning

Más detalles

DEPARTAMENTO ESTATAL DE SERVICIOS DE SALUD DE TEXAS

DEPARTAMENTO ESTATAL DE SERVICIOS DE SALUD DE TEXAS DEPARTAMENTO ESTATAL DE SERVICIOS DE SALUD DE TEXAS DAVID L. LAKEY, M.D. DIRECTOR P.O. Box 149347 Austin, Texas 78714-9347 1-888-963-7111 TTY (teletipo): 1-800-735-2989 www.dshs.state.tx.us 1 de marzo,

Más detalles

I am the parent or legal guardian of.

I am the parent or legal guardian of. EXHIBIT Descriptive Code: IFCB-R/E (2) FIELD TRIPS AND EXCURSIONS Date: March 9, 2006 Clarke County School District Student Travel Authorization and Teacher ation Form To SCHOOL: I am the parent or legal

Más detalles

HEAD START MEDICATION ADMINISTRATION

HEAD START MEDICATION ADMINISTRATION HEAD START MEDICATION ADMINISTRATION Dear Parents/Guardians: It is the policy of Head Start to cooperate with each Head Start child's parent/guardian and his/her physician by administering and providing

Más detalles

OJO: Todos los formularios deberán llenarse en inglés. De lo contrario, no se le permitirá presentar sus documentos ante la Secretaría del Tribunal.

OJO: Todos los formularios deberán llenarse en inglés. De lo contrario, no se le permitirá presentar sus documentos ante la Secretaría del Tribunal. OJO: Todos los formularios deberán llenarse en inglés. De lo contrario, no se le permitirá presentar sus documentos ante la Secretaría del Tribunal. For Clerk s Use Only (Para uso de la Secretaria solamente)

Más detalles

News Flash! Primary & Specialty Care Providers. Sharp Health Plan. Date: February 17, 2012. Subject: Member Grievance Forms

News Flash! Primary & Specialty Care Providers. Sharp Health Plan. Date: February 17, 2012. Subject: Member Grievance Forms I M P O R T A N T News Flash! A FAX Publication for Providers of Sharp Health Plan To: From: Primary & Specialty Care Providers Sharp Health Plan Date: February 17, 2012 Subject: Member Grievance Forms

Más detalles

CONSENT FOR HIV BLOOD TEST

CONSENT FOR HIV BLOOD TEST i have been informed that a sample of my blood will be obtained and tested to determine the presence of antibodies to human immunodeficiency Virus (hiv), the virus that causes Acquired immune Deficiency

Más detalles

PB #11-111-OPE. Attachment: Please use Print on M-687r Referral to Treatment Program (Rev. 11/30/11) (Rev. 11/30/11)

PB #11-111-OPE. Attachment: Please use Print on M-687r Referral to Treatment Program (Rev. 11/30/11) (Rev. 11/30/11) FAMILY INDEPENDENCE ADMINISTRATION Matthew Brune, Executive Deputy Commissioner James K. Whelan, Deputy Commissioner Policy, Procedures, and Training Stephen Fisher, Assistant Deputy Commissioner Office

Más detalles

Lump Sum Final Check Contribution to Deferred Compensation

Lump Sum Final Check Contribution to Deferred Compensation Memo To: ERF Members The Employees Retirement Fund has been asked by Deferred Compensation to provide everyone that has signed up to retire with the attached information. Please read the information from

Más detalles

LOS ANGELES UNIFIED SCHOOL DISTRICT OFFICE OF PERMITS AND STUDENT TRANSERS

LOS ANGELES UNIFIED SCHOOL DISTRICT OFFICE OF PERMITS AND STUDENT TRANSERS INTER-DISTRICT PERMIT APPEALS If your inter-district permit application has been denied cancelled, or revoked, you may appeal the decision if you believe that an exception to district policy is warranted

Más detalles

UNIVERSIDAD DE UTAH LEY PARA PERSONAS CON DISCAPACIDADES ADA AMERICANS WITH DISABILITIES ACT SOLICITUD DE ACOMODO

UNIVERSIDAD DE UTAH LEY PARA PERSONAS CON DISCAPACIDADES ADA AMERICANS WITH DISABILITIES ACT SOLICITUD DE ACOMODO UNIVERSIDAD DE UTAH LEY PARA PERSONAS CON DISCAPACIDADES ADA AMERICANS WITH DISABILITIES ACT SOLICITUD DE ACOMODO Office of Equal Opportunity and Affirmative Action (OEO/AA) 135 Park Building 201 South

Más detalles

PROCEDIMIENTOS: QUÉ HACER CON EL PEDIMENTO UNA VEZ QUE SE HA COMPLETADO

PROCEDIMIENTOS: QUÉ HACER CON EL PEDIMENTO UNA VEZ QUE SE HA COMPLETADO CENTRO DE AUTOSERVICIO PROCEDIMIENTOS: QUÉ HACER CON EL PEDIMENTO UNA VEZ QUE SE HA COMPLETADO PASO 1: COPIAS Y SOBRES. Haga tres (3) copias de las páginas siguientes del pedimento; Haga dos (2) copias

Más detalles

Welcome to the CU at School Savings Program!

Welcome to the CU at School Savings Program! Welcome to the CU at School Savings Program! Thank you for your interest in Yolo Federal Credit Union s CU at School savings program. This packet of information has everything you need to sign your child

Más detalles

INSTRUCTIONS FOR PREPARING THE RESEARCH AUTHORIZATION FORM:

INSTRUCTIONS FOR PREPARING THE RESEARCH AUTHORIZATION FORM: 550 First Ave. Building #VET 10 West NY, NY 10016 Phone: 212.263.4110 Fax: 212.263.4147 INSTRUCTIONS FOR PREPARING THE RESEARCH AUTHORIZATION FORM: Please note that this shaded gray section is for instruction

Más detalles

LOS ANGELES UNIFIED SCHOOL DISTRICT STUDENT EMERGENCY INFORMATION FORM Parent Information: Please fill out completely and sign where indicated. In a major emergency, it is school district policy to retain

Más detalles

Student and Adult Release Forms

Student and Adult Release Forms Student and Adult Release Forms The following sample release forms are provided along with an explanation of the forms and your responsibility. For Tasks 3 and 4, your response will be based, in part,

Más detalles

Web: www.bcapfund.org, email: bcapfund@bcapfund.org. Programa local de caridad en Tulsa

Web: www.bcapfund.org, email: bcapfund@bcapfund.org. Programa local de caridad en Tulsa Programa local de caridad en Tulsa Ayudando a Pacientes en su Jornada de Recuperación Formulario de solicitud de ayuda Revisado 11.15 BCAP Mision: Para asistir a pacientes que estén en tratamientos de

Más detalles

PRINTING INSTRUCTIONS

PRINTING INSTRUCTIONS PRINTING INSTRUCTIONS 1. Print the Petition form on 8½ X 11inch paper. 2. The second page (instructions for circulator) must be copied on the reverse side of the petition Instructions to print the PDF

Más detalles

FAMILY MEDICAL CENTRE

FAMILY MEDICAL CENTRE FAMILY MEDICAL CENTRE Patient Information Sheet / Informacion del Paciente DATE: Fecha LAST NAME: FIRST NAME / MI: Apellido Nombre / Inicial ADDRESS: APT #: CITY / STATE: ZIP: Direccion Ciudad / Estado

Más detalles

TITLE VI COMPLAINT FORM

TITLE VI COMPLAINT FORM TITLE VI COMPLAINT FORM Before filling out this form, please read the Arcata and Mad River Transit System Title VI Complaint Procedures located on our website or by visiting our office. The following information

Más detalles

FINANCIAL MANAGEMENT SERVICES RISK MANAGEMENT. Procedures for Filing Your Claim

FINANCIAL MANAGEMENT SERVICES RISK MANAGEMENT. Procedures for Filing Your Claim FINANCIAL MANAGEMENT SERVICES RISK MANAGEMENT Procedures for Filing Your Claim Notice: Prerequisite to Lawsuit for Damages Charter XXVII, Section 25, Charter of the City of Fort Worth States in part,.

Más detalles

HOMEWORK HELP PROGRAM STUDENT REQUIREMENTS STUDENT GUIDELINES

HOMEWORK HELP PROGRAM STUDENT REQUIREMENTS STUDENT GUIDELINES HOMEWORK HELP PROGRAM This program is a cooperative learning experience shared between high school and elementary school students in the East Ramapo Central School District. It is designed to match Elementary

Más detalles

Title VI Complaint Procedures

Title VI Complaint Procedures Title VI Complaint Procedures As a recipient of federal dollars, HELP of Ojai, Inc. is required to comply with Title VI of the Civil Rights Act of 1964 and ensure that services and benefits are provided

Más detalles

As the 2013-14 school year comes to a close, Camden City School District is excited to get summer programming underway!

As the 2013-14 school year comes to a close, Camden City School District is excited to get summer programming underway! June 2014 Dear Parents and Guardians: As the 2013-14 school year comes to a close, Camden City School District is excited to get summer programming underway! The District Summer School Program will operate

Más detalles

BIENVENIDOS A LA OFICINA DEL DR. VICTOR LOOS. Por favor revise y llene las siguientes formas:

BIENVENIDOS A LA OFICINA DEL DR. VICTOR LOOS. Por favor revise y llene las siguientes formas: BIENVENIDOS A LA OFICINA DEL DR. VICTOR LOOS Por favor revise y llene las siguientes formas: Notice of Privacy of Policy (Aviso de privacidad al paciente) Leer y puede quedarse con él Informacion del Cliente

Más detalles

INFORMACION BASICA DEL PACIENTE

INFORMACION BASICA DEL PACIENTE INFORMACION BASICA DEL PACIENTE Apellido del paciente Primer nombre Segundo nombre Dirección Número de apartamento Ciudad Estado Código Postal Teléfono primario ( ) Secundario ( ) Trabajo ( ) Fecha de

Más detalles

I understand that I must request that this waiver be reconsidered annually, each school year. Parent/Guardian Signature: Date:

I understand that I must request that this waiver be reconsidered annually, each school year. Parent/Guardian Signature: Date: Page 1 of 7 PARENTAL EXCEPTION WAIVER EDUCATION CODE 311(a): Children who know English (Exhibit 1) Name: School: Grade: Date of Birth: Language Designation: My child possesses good English language skills

Más detalles

TITLE VI COMPLAINT FORM

TITLE VI COMPLAINT FORM [CITY SEAL/EMBLEM] The Capital City of the Palm Beaches TITLE VI COMPLAINT FORM Title VI of the 1964 Civil Rights Act requires that "No person in the United States shall, on the ground of race, color or

Más detalles

IRS DATA RETRIEVAL NOTIFICATION DEPENDENT STUDENT ESTIMATOR

IRS DATA RETRIEVAL NOTIFICATION DEPENDENT STUDENT ESTIMATOR IRS DATA RETRIEVAL NOTIFICATION DEPENDENT STUDENT ESTIMATOR Subject: Important Updates Needed for Your FAFSA Dear [Applicant], When you completed your 2012-2013 Free Application for Federal Student Aid

Más detalles

School Preference through the Infinite Campus Parent Portal

School Preference through the Infinite Campus Parent Portal School Preference through the Infinite Campus Parent Portal Welcome New and Returning Families! Enrollment for new families or families returning to RUSD after being gone longer than one year is easy.

Más detalles

Guide to Health Insurance Part II: How to access your benefits and services.

Guide to Health Insurance Part II: How to access your benefits and services. Guide to Health Insurance Part II: How to access your benefits and services. 1. I applied for health insurance, now what? Medi-Cal Applicants If you applied for Medi-Cal it will take up to 45 days to find

Más detalles

\RESOURCE\ELECTION.S\PROXY.CSP

\RESOURCE\ELECTION.S\PROXY.CSP The following is an explanation of the procedures for calling a special meeting of the shareholders. Enclosed are copies of documents, which you can use for your meeting. If you have any questions about

Más detalles

Migrant. Learners Today LEADERS Tomorrow!

Migrant. Learners Today LEADERS Tomorrow! Migrant Learners Today LEADERS Tomorrow! 2014 Migrant Summer Program Language Enrichment for English Language Learners Through Science Themes Students will enhance English language acquisition through

Más detalles

Are you interested in helping to GOVERN the Authority, DEVELOP current and future programs, and APPROVE contracts?

Are you interested in helping to GOVERN the Authority, DEVELOP current and future programs, and APPROVE contracts? Albany Housing Authority RESIDENT COMMISSIONER ELECTION Are you interested in helping to GOVERN the Authority, DEVELOP current and future programs, and APPROVE contracts? RUN FOR RESIDENT COMMISSIONER

Más detalles

Rhode Island Department of Health Three Capitol Hill Providence, RI 02908-5094

Rhode Island Department of Health Three Capitol Hill Providence, RI 02908-5094 Rhode Island Department of Health Three Capitol Hill Providence, RI 02908-5094 www.health.ri.gov Date: December 30, 2009 To: Parents and guardians of school-aged children in Rhode Island From: Director

Más detalles

Goodwill Serving the People of Southern Los Angeles County. Title VI Notice to the Public

Goodwill Serving the People of Southern Los Angeles County. Title VI Notice to the Public Title VI Notice to the Public Notifying the Public of Rights Under Title VI (Goodwill SOLAC) operates its programs and services without regard to race, color, and national origin in accordance with Title

Más detalles

2015 16 Student Eligibility Verification Advanced Placement/International Baccalaureate Test Fee Program

2015 16 Student Eligibility Verification Advanced Placement/International Baccalaureate Test Fee Program 2015 16 Student Eligibility Verification Advanced Placement (AP) and/or International Baccalaureate (IB) Exams AP Exam IB Exam AP and IB Exams I. Student Information Last Name First Name MI Grade High

Más detalles

Passaic County Technical Institute 45 Reinhardt Road Wayne, New Jersey 07470

Passaic County Technical Institute 45 Reinhardt Road Wayne, New Jersey 07470 Note: Instructions in Spanish immediately follow instructions in English (Instrucciones en español inmediatamente siguen las instrucciónes en Inglés) Passaic County Technical Institute 45 Reinhardt Road

Más detalles

RENT CONTROL BOARD OF THE TOWN OF WEST NEW YORK, N.J. 428-60 TH STREET WEST NEW YORK, N.J. 07093-2231 (201) 295-5290/91/92

RENT CONTROL BOARD OF THE TOWN OF WEST NEW YORK, N.J. 428-60 TH STREET WEST NEW YORK, N.J. 07093-2231 (201) 295-5290/91/92 FELIX E. ROQUE, MD MAYOR DEPT. OF PUBLIC AFFAIRS RENT CONTROL BOARD RENTAL AGREEMENT APPLICATION NAME OF ADDRESS OF LANDLORD: PROPERTY ADDRESS: APARTMENT #: 3 COPIES (1) Original rental agreement signed

Más detalles

Title VI Complaint Form Horizon Cross Cultural Center (HORIZON) (formerly St. Anselm s Cross-Cultural Community Center) Office of Civil Rights

Title VI Complaint Form Horizon Cross Cultural Center (HORIZON) (formerly St. Anselm s Cross-Cultural Community Center) Office of Civil Rights Title VI Complaint Form Horizon Cross Cultural Center (HORIZON) (formerly St. Anselm s Cross-Cultural Community Center) Title VI of the Civil Rights Act of 1964 provides that no person in the United States

Más detalles

WIRB 20151878 #13553129.0

WIRB 20151878 #13553129.0 WIRB 20151878 #13553129.0 Florida Health Care Coalition Diabetes Program Congratulations, now that you have viewed Education Session #1 here is what you need to do to enroll in the research portion of

Más detalles

WRAPAROUND MILWAUKEE Policy & Procedure

WRAPAROUND MILWAUKEE Policy & Procedure WRAPAROUND MILWAUKEE Policy & Procedure Wraparound Wraparound-REACH FISS Project O-Yeah Date Issued: 9/1/98 Effective Date: 1/1/13 Reviewed: 10/23/12 DT Last Revision: 10/25/12 Subject: Section: ADMINISTRATION

Más detalles

Daly Elementary. Family Back to School Questionnaire

Daly Elementary. Family Back to School Questionnaire Daly Elementary Family Back to School Questionnaire Dear Parent(s)/Guardian(s), As I stated in the welcome letter you received before the beginning of the school year, I would be sending a questionnaire

Más detalles

Chattanooga Motors - Solicitud de Credito

Chattanooga Motors - Solicitud de Credito Chattanooga Motors - Solicitud de Credito Completa o llena la solicitud y regresala en persona o por fax. sotros mantenemos tus datos en confidencialidad. Completar una aplicacion para el comprador y otra

Más detalles

For more information regarding these forms please go to the Texas Department of Insurance website http://www.tdi.state.tx.us/forms/form20employer.

For more information regarding these forms please go to the Texas Department of Insurance website http://www.tdi.state.tx.us/forms/form20employer. CAPROCK Claims Management, LLC ROCK SOLID PERFORMANCE AND RESULTS PO Box 743427 Dallas, TX 75374 (888) 812-3577 Fax (972) 934-3091 IMPORTANT NOTICE FOR REQUIRED FILING FORMS DWC FORM-5 & DWC FORM-7 Caprock

Más detalles

Becoming Independent Title VI Program

Becoming Independent Title VI Program Title VI Complaint Procedures As a recipient of federal fund, Becoming Independent is required to comply with Title VI of the Civil Rights Act of 1964 and ensure that program and services are provided

Más detalles

School Compact Flat Rock Middle School School Year 2015-2016

School Compact Flat Rock Middle School School Year 2015-2016 School Compact School Year 2015-2016 Dear Parent/Guardian, Flat Rock Middle, students participating in the Title I, Part A program, and their families, agree that this compact outlines how the parents,

Más detalles

Southern California Lumber Industry Retirement Fund

Southern California Lumber Industry Retirement Fund Southern California Lumber Industry Retirement Fund Established Jointly by Employers and Local Unions Telephone (562) 463-5080 (800) 824-4427 Facsimile (562) 463-5894 www.lumberfund.org January 9, 2015

Más detalles

School Food and Nutrition Services - 703.791.7314 Facilities Management Services - 703.791.7221

School Food and Nutrition Services - 703.791.7314 Facilities Management Services - 703.791.7221 SUPPORT SERVICES To: All Principals All Food Service Managers Approved by: Dave Cline Contact Person: Serena Suthers SUPPORT SERVICES Spring Break Refrigerator/Freezer Checks This notice remains in effect

Más detalles

Welcome Savers! 1. Fill out application form if you re not already a Yolo FCU member.

Welcome Savers! 1. Fill out application form if you re not already a Yolo FCU member. Welcome Savers! Yolo Federal Credit Union and Montgomery Elementary School have teamed up again this year to bring you our school saving program! It s easy to participate... 1. Fill out application form

Más detalles

Down Payment Assistance Application Packet

Down Payment Assistance Application Packet Down Payment Assistance Application Packet Please assure that all needed items are attached and complete. Please note that your application will not be considered until all documents are received. 1. Down

Más detalles

2014 15 Student Eligibility Verification Advanced Placement/International Baccalaureate Test Fee Program

2014 15 Student Eligibility Verification Advanced Placement/International Baccalaureate Test Fee Program 2014 15 Student Eligibility Verification Advanced Placement (AP) and/or International Baccalaureate (IB) Exams þ AP Exam IB Exam AP and IB Exams I. Student Information Last Name First Name MI Grade High

Más detalles

Cómo comprar en la tienda en línea de UDP y cómo inscribirse a los módulos UDP

Cómo comprar en la tienda en línea de UDP y cómo inscribirse a los módulos UDP Cómo comprar en la tienda en línea de UDP y cómo inscribirse a los módulos UDP Sistema de registro y pago Este sistema está dividido en dos etapas diferentes*. Por favor, haga clic en la liga de la etapa

Más detalles

Exceptional Children s Foundation Title VI Notice to the Public

Exceptional Children s Foundation Title VI Notice to the Public Title VI Notice to the Public Notifying the Public of Rights Under Title VI Exceptional Children s Foundation The Exceptional Children s Foundation (ECF) operates its programs and services without regard

Más detalles

OJO: Todos los formularios deberán completarse en inglés. De lo contrario, no se le permitirá presentar sus documentos en la Secretaría del Tribunal.

OJO: Todos los formularios deberán completarse en inglés. De lo contrario, no se le permitirá presentar sus documentos en la Secretaría del Tribunal. OJO: Todos los formularios deberán completarse en inglés. De lo contrario, no se le permitirá presentar sus documentos en la Secretaría del Tribunal. Person Filing: (Nombre de persona:) Address (if not

Más detalles

Title VI Complaint Procedures

Title VI Complaint Procedures Title VI Complaint Procedures As a recipient of federal fund, Self-Help for the Elderly is required to comply with Title VI of the Civil Rights Act of 1964 and ensure that program and services are provided

Más detalles

Cal Grant GPA Electronic Submission and Opt-out Notification As of 10.13.15

Cal Grant GPA Electronic Submission and Opt-out Notification As of 10.13.15 12338 McCourtney Road Grass Valley, CA 95949 Phone: 530-272-4008 Fax: 530-272-4009 www.johnmuircs.com Cal Grant GPA Electronic Submission and Opt-out Notification As of 10.13.15 Assembly Bill 2160, commonly

Más detalles

El límite mínimo para las cuentas comerciales grandes es de $2,000/mes por el uso del servicio.

El límite mínimo para las cuentas comerciales grandes es de $2,000/mes por el uso del servicio. ONNETIUT OBERTURA DEL FORMULARIO DE FAX PARA: XOOM Energy lientes omerciales No. FAX: 866.452.0053 FEHA: NOMBRE DE EMPRESARIO INDEPENDIENTE: # IDENTIFIAIÓN DE NEGOIO: ORREO ELETRÓNIO: # DE PÁGINAS: TELÉFONO:

Más detalles

MISSISSIPPI EMPLOYEES

MISSISSIPPI EMPLOYEES 1961 Diamond Springs Road Virginia Beach, VA 23455 Phone (757) 460-6308 Fax (757) 457-9345 MISSISSIPPI EMPLOYEES MANCON Employees, Included in this packet is the following information: 1. Job Insurance

Más detalles

Setting Up an Apple ID for your Student

Setting Up an Apple ID for your Student Setting Up an Apple ID for your Student You will receive an email from Apple with the subject heading of AppleID for Students Parent/Guardian Information Open the email. Look for two important items in

Más detalles

Northwestern University, Feinberg School of Medicine

Northwestern University, Feinberg School of Medicine Improving Rates of Repeat Colorectal Cancer Screening Appendix Northwestern University, Feinberg School of Medicine Contents Patient Letter Included with Mailed FIT... 3 Automated Phone Call... 4 Automated

Más detalles

Purpose of Sliding Scale Policy and Procedure Disclaimer Policy

Purpose of Sliding Scale Policy and Procedure Disclaimer Policy San Luis Valley Health s Behavioral Health department offers a sliding fee discount program to eligible patients. If you would like more information, please call 589-8008, or ask one of our Admitting Clerks

Más detalles

Frequently Asked Questions Vaccine Exemption for Reasons of Conscience

Frequently Asked Questions Vaccine Exemption for Reasons of Conscience Frequently Asked Questions Vaccine Exemption for Reasons of Conscience Q. How do I obtain a vaccine exemption for reasons of conscience for my child? A. Parents or guardians need to request a vaccine exemption

Más detalles

FAMILY INDEPENDENCE ADMINISTRATION Seth W. Diamond, Executive Deputy Commissioner

FAMILY INDEPENDENCE ADMINISTRATION Seth W. Diamond, Executive Deputy Commissioner FAMILY INDEPENDENCE ADMINISTRATION Seth W. Diamond, Executive Deputy Commissioner James K. Whelan, Deputy Commissioner Policy, Procedures, and Training Lisa C. Fitzpatrick, Assistant Deputy Commissioner

Más detalles

Adult Application 18 and over ONLY ******************************** Aplicación de Adultos Solo para mayores de 18 años

Adult Application 18 and over ONLY ******************************** Aplicación de Adultos Solo para mayores de 18 años Adult Application 18 and over ONLY ******************************** Aplicación de Adultos Solo para mayores de 18 años FREE GRATIS Beacon Programs Adult Enrollment Form Beacon PROGRAMS Participant Information

Más detalles

CPS-Parent Portal Portal Para Padres

CPS-Parent Portal Portal Para Padres CPS-Parent Portal Portal Para Padres Marie Sklodowska Curie Metro High School A#endance Office - Room 187 (773) 535-2150 GEAR UP - Parent Services Room 187-190 (773) 535-9833 Behind Every Successful Student

Más detalles

Steps to Understand Your Child s Behavior. Customizing the Flyer

Steps to Understand Your Child s Behavior. Customizing the Flyer Steps to Understand Your Child s Behavior Customizing the Flyer Hello! Here is the PDF Form Template for use in advertising Steps to Understanding Your Child s Behavior (HDS Behavior Level 1B). Because

Más detalles

New Patient Intake (Nuevo Paciente)

New Patient Intake (Nuevo Paciente) Dr. James R. Saeli, DC Phone: (919) 246-9497 3001 Academy Rd., Ste. 230 Fax: (919) 403-2917 Durham, NC 27707 www.migrainehelpdurham.com New Patient Intake (Nuevo Paciente) Titulo: Dr. /a. Sr. Sra. Srta.

Más detalles

United States Spain Treaties in Force

United States Spain Treaties in Force Alien Amateur Radio Operators Agreement effected by exchange of notes Signed at Madrid December 11 and 20, 1979; Entered into force December 20, 1979. TIAS 9721 STATUS: Agreement effected by exchange of

Más detalles

Otros datos pertinentes:

Otros datos pertinentes: REGISTRO DE CUIDADO DE NIÑOS EN EL HOGAR CHILD CARE HOME REGISTER FECHA DE COMIENZO DE CUIDADO DEL NIÑO FECHA DE TERMINACIÓN DE CUIDADO DEL NIÑO NOMBRE DEL NIÑO APELLIDO PRIMER NOMBRE SEGUNDO NOMBRE USADO

Más detalles

POLICA FINANCERIA Y CONSENTIMENTO PARA TRATAMENTO

POLICA FINANCERIA Y CONSENTIMENTO PARA TRATAMENTO POLICA FINANCERIA Y CONSENTIMENTO PARA TRATAMENTO Nuestra Póliza Financiera: Nuestros doctores y personal están muy preocupados de los costos de su tratamiento medico y queremos discutiré algunos temas

Más detalles

INFORMACIÓN PARA ABRIR UNA GUARDERÍA DE NIÑOS PARA FAMILIAS O GRUPOS EN LA CIUDAD DE ALLENTOWN

INFORMACIÓN PARA ABRIR UNA GUARDERÍA DE NIÑOS PARA FAMILIAS O GRUPOS EN LA CIUDAD DE ALLENTOWN INFORMACIÓN PARA ABRIR UNA GUARDERÍA DE NIÑOS PARA FAMILIAS O GRUPOS EN LA CIUDAD DE ALLENTOWN Informacion importante de saber: Una guarderia de niños para familias consite de un niño hasta 6 niños. Una

Más detalles

ODJFS Bureau of Civil Rights. ODJFS Bureau of Civil Rights. ODJFS Bureau of Civil Rights. ODJFS Bureau of Civil Rights

ODJFS Bureau of Civil Rights. ODJFS Bureau of Civil Rights. ODJFS Bureau of Civil Rights. ODJFS Bureau of Civil Rights ODJFS Bureau of Civil Rights I NEED AN INTERPRETER, PLEASE. Title VI of the Civil Rights Act of 1964 prohibits discrimination on the basis of national origin. If you do not speak English well, social services,

Más detalles

PODER NOTARIAL DE UN MENOR DE EDAD

PODER NOTARIAL DE UN MENOR DE EDAD POWER OF ATTORNEY OVER A MINOR PODER NOTARIAL DE UN MENOR DE EDAD PUEDE USAR ESTE PAQUETE SÓLO SI SE CUMPLEN TODAS LAS SIGUIENTES CONDICIONES:! Usted desea dar autoridad temporal sobre su hijo a otra persona.!

Más detalles

Financial Affidavit for Child Support, DC 6:5(2) Declaración Jurada de Finanzas para Manutención de Menores, DC 6:5(2).

Financial Affidavit for Child Support, DC 6:5(2) Declaración Jurada de Finanzas para Manutención de Menores, DC 6:5(2). IN THE DISTRICT CURT F CUNTY, NEBRASKA (county where Complaint filed) EN LA CRTE DE DISTRIT DEL CNDAD DE, NEBRASKA (condado donde se entabló la Demanda), ) (your full name) (su nombre completo) ) Plaintiff,/

Más detalles

SUNRISE PEDIATRICS SANJAY KANDOTH, MD 3061 S MARYLAND PARKWAY SUITE #101 LAS VEGAS, NV 89109 PH # 702-254-KIDS (5437) FAX # 702-254-7354

SUNRISE PEDIATRICS SANJAY KANDOTH, MD 3061 S MARYLAND PARKWAY SUITE #101 LAS VEGAS, NV 89109 PH # 702-254-KIDS (5437) FAX # 702-254-7354 SUNRISE PEDIATRICS SANJAY KANDOTH, MD 3061 S MARYLAND PARKWAY SUITE #101 LAS VEGAS, NV 89109 PH # 702-254-KIDS (5437) FAX # 702-254-7354 NEW PATIENT REGISTRATION FORM FORMA DE REGISTRACION PARA PACIENTES

Más detalles

ANNUAL REPORT OF GUARDIAN ON CONDITION OF WARD/INCAPACITATED PERSON INFORME ANUAL DEL TUTOR SOBRE LA CONDICIÓN DEL PUPILO/PERSONA INCAPACITADA/INHÁBIL

ANNUAL REPORT OF GUARDIAN ON CONDITION OF WARD/INCAPACITATED PERSON INFORME ANUAL DEL TUTOR SOBRE LA CONDICIÓN DEL PUPILO/PERSONA INCAPACITADA/INHÁBIL Nebraska State Court Form REQUIRED Formulario del Tribunal del Estado de Nebraska REQUERIDO ANNUAL REPORT OF GUARDIAN ON CONDITION OF WARD/INCAPACITATED PERSON INFORME ANUAL DEL TUTOR SOBRE LA CONDICIÓN

Más detalles

Arquidiócesis de Atlanta St. John Vianney Excursión Formulario de consentimiento de los padres/tutores y exoneración de responsabilidades

Arquidiócesis de Atlanta St. John Vianney Excursión Formulario de consentimiento de los padres/tutores y exoneración de responsabilidades Middle School and High School Retreat March 15-17 Cost $60.00 Per Student 90.00 If you have 2 students attending These retreats are 2 separate retreats held at the same camp. The students preparing for

Más detalles

Escuela Olympic Program Titulo 1

Escuela Olympic Program Titulo 1 Escuela Olympic Program Titulo 1 Misión: Creemos que toda la comunidad de alumnos de Olympic van aprender Creemos que el habiente de posibilidad da lugar para la capacidad Nosotros esfuerzos nos ha logrado

Más detalles

ACCEPTANCE OF APPOINTMENT OF GUARDIAN AND CONSERVATOR ACEPTACIÓN AL NOMBRAMIENTO DE TUTOR Y CURADOR

ACCEPTANCE OF APPOINTMENT OF GUARDIAN AND CONSERVATOR ACEPTACIÓN AL NOMBRAMIENTO DE TUTOR Y CURADOR Nebraska State Court Form Formulario del Tribunal del Estado de Nebraska REQUIRED REQUERIDO ACCEPTANCE OF APPOINTMENT OF GUARDIAN AND CONSERVATOR ACEPTACIÓN AL NOMBRAMIENTO DE TUTOR Y CURADOR CC 16:2.5

Más detalles

Registro de Semilla y Material de Plantación

Registro de Semilla y Material de Plantación Registro de Semilla y Material de Plantación Este registro es para documentar la semilla y material de plantación que usa, y su estatus. Mantenga las facturas y otra documentación pertinente con sus registros.

Más detalles

La Compensación por Desempleo Instrucciones para Solicitar los Documentos de la Proposición de Pruebas

La Compensación por Desempleo Instrucciones para Solicitar los Documentos de la Proposición de Pruebas La Compensación por Desempleo Instrucciones para Solicitar los Documentos de la Proposición de Pruebas Si tiene un caso pendiente ante la Oficina de Apelaciones de casos de Compensación por Desempleo,

Más detalles

Canutillo Middle School 7311 Bosque, P.O. Box 100 Canutillo, Texas 79835 (915) 877-7900 Fax (915) 877-7919

Canutillo Middle School 7311 Bosque, P.O. Box 100 Canutillo, Texas 79835 (915) 877-7900 Fax (915) 877-7919 Mark Paz August 24, 2015 Dear Parents/Legal Guardian, I would like to start by thanking each and every single one of you for the tremendous help and support we have been receiving. Thank You! Next school

Más detalles

Thank you. US English US Spanish. Australia-English Canada-English Ireland-English New Zealand-English Taiwan-English United Kingdom-English

Thank you. US English US Spanish. Australia-English Canada-English Ireland-English New Zealand-English Taiwan-English United Kingdom-English Dear Healthcare Provider, Included in this PDF are recruitment brochures in several languages to be used in MM Bone study (Protocol No.: 20090482). Kindly note these brochures have been updated according

Más detalles

More child support paid + more passed

More child support paid + more passed Child Support and W-2 are working together to better serve Wisconsin families. More child support is paid when families understand the rules. Recent child support policy changes are giving more money back

Más detalles

SFGH FHC Healthy Children Vaccination Program Frequently Asked Questions

SFGH FHC Healthy Children Vaccination Program Frequently Asked Questions SFGH FHC Healthy Children Vaccination Program Frequently Asked Questions The Family Health Center (FHC) Healthy Children Vaccination Program at SF General Hospital (SFGH) provides immunization services

Más detalles

MajestaCare Healthy Baby Program

MajestaCare Healthy Baby Program MajestaCare Healthy Baby Program Helping you have a healthy baby Para que tenga un bebé saludable Your baby s provider After your baby becomes a member of MajestaCare health plan, you will get a letter

Más detalles

Workers Compensation Non-Subscriber Form

Workers Compensation Non-Subscriber Form Workers Compensation Non-Subscriber Form Texas is unique in one very important respect: It s the only state in which employers have the choice to carry workers compensation insurance or not. There are

Más detalles

ANTES DE ENTREGAR SU SOLICITUD! ASISTENCIA. STONEBRIAR COMMUNITY CHURCH (SCC) NO OFRECE AYUDA INMEDIATA. AYUDA. APROPIADOS.

ANTES DE ENTREGAR SU SOLICITUD! ASISTENCIA. STONEBRIAR COMMUNITY CHURCH (SCC) NO OFRECE AYUDA INMEDIATA. AYUDA. APROPIADOS. ATENCIÓN!!! FAVOR DE LEER Y PONER SUS INÍCIALES EN ESTA PÁGINA ANTES DE ENTREGAR SU SOLICITUD! SI USTED NO PROVEE LO REQUERIDO, NO RECIBIRÁ ASISTENCIA. STONEBRIAR COMMUNITY CHURCH (SCC) NO OFRECE AYUDA

Más detalles

Dear Parents and Patrons,

Dear Parents and Patrons, Dear Parents and Patrons, The purpose of this letter is to inform you that according to the 2013-14 state student assessment results NeSA reading, Gibbon Elementary School is considered a Title 1 School

Más detalles

Fall Notice to Beneficiaries Enrolled in Low Performing Plans Information for SHIPs

Fall Notice to Beneficiaries Enrolled in Low Performing Plans Information for SHIPs Fall Notice to Beneficiaries Enrolled in Low Performing Plans Information for SHIPs CMS is sending a notice to Medicare beneficiaries currently enrolled in consistently low performing plans. This notice

Más detalles

Tarjetas de crédito Visa y Mastercard a través de la pagina de inscripción al curso. (En Argentina no se acepta Amex)

Tarjetas de crédito Visa y Mastercard a través de la pagina de inscripción al curso. (En Argentina no se acepta Amex) Terminos y Condiciones PAGOS El pago del curso deberá en todos los casos efectivizado como mínimo - 72 horas antes del comienzo del mismo. La vacante será confirmada contra el pago del curso, hasta ese

Más detalles

Learning Masters. Early: Force and Motion

Learning Masters. Early: Force and Motion Learning Masters Early: Force and Motion WhatILearned What important things did you learn in this theme? I learned that I learned that I learned that 22 Force and Motion Learning Masters How I Learned

Más detalles

Deposits and Withdrawals policy. Política de Depósitos y Retiradas

Deposits and Withdrawals policy. Política de Depósitos y Retiradas Deposits and Withdrawals policy Política de Depósitos y Retiradas TeleTrade-DJ International Consulting Ltd 2011-2014 TeleTrade-DJ International Consulting Ltd. 1 Bank Wire Transfers: When depositing by

Más detalles

Orden de domiciliación o mandato para adeudos directos SEPA. Esquemas Básico y B2B

Orden de domiciliación o mandato para adeudos directos SEPA. Esquemas Básico y B2B Orden de domiciliación o mandato para adeudos directos SEPA. Esquemas Básico y B2B serie normas y procedimientos bancarios Nº 50 Abril 2013 INDICE I. Introducción... 1 II. Orden de domiciliación o mandato

Más detalles